Etiology and outcome of lower gastrointestinal bleeding in patients with AIDS

Evaluation and management of lower gastrointestinal bleeding

Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.

Risk and mortality of gastrointestinal hemorrhage in patients with thrombocytopenia: Two nationwide retrospective cohort studies

INTRODUCTION

The association between thrombocytopenia (TP) and gastrointestinal hemorrhage was not completely understood. The purpose of this study is to evaluate the risk of gastrointestinal hemorrhage and post-hemorrhage mortality in patients with TP.

METHODS

Using the Taiwan National Health Insurance Research Database, we identified 1033 adults aged ≥18 years diagnosed with TP in 2000-2003. Non-TP cohort consisted of 10,330 adults randomly selected and matched by age and sex from the same dataset. Incident events of gastrointestinal hemorrhage occurring after TP from January 1, 2000, through December 31, 2008, were ascertained from medical claims. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of gastrointestinal hemorrhage associated with TP were calculated. Another nested cohort study consisted of 27,369 patients with hospitalization due to gastrointestinal hemorrhage between January 1, 2004, and December 31, 2010. We calculated the adjusted odds ratios (ORs) and 95% CIs of 30-day mortality after gastrointestinal hemorrhage in patients with and without TP during admission.

RESULTS

The incidences of gastrointestinal hemorrhage for people with and without TP were 14.5 and 5.07 per 1000 person-years, respectively (P<0.0001). Compared to people without TP, patients with TP had increased risk of gastrointestinal hemorrhage (HR, 2.61; 95% CI, 2.05-3.32). In the nested cohort study, TP was associated with post-hemorrhage mortality (OR, 1.98; 95% CI, 1.09-3.59).

CONCLUSION

Patients with TP showed higher risks of gastrointestinal hemorrhage and post-hemorrhage mortality. Our findings suggest the urgency of preventing and managing gastrointestinal hemorrhage by a multidisciplinary medical team for this specific population.

Lower gastrointestinal bleeding

This article examines causes of occult, moderate and severe lower gastrointestinal (GI) bleeding. The difference in the workup of stable vs unstable patients is stressed. Treatment options ranging from minimally invasive techniques to open surgery are explored.

Small bowel perforation due to CMV enteritis infection in an HIV-positive patient

BACKGROUND

Cytomegalovirus infection of the gastrointestinal tract is common and is more often seen in patients with acquired immunodeficiency syndrome (AIDS). Although small bowel infection is less common than infection of other parts of the gastrointestinal system, it may lead to perforation, an acute complication, with dreadful results.

CASE PRESENTATION

This article reports a case of Cytomegalovirus ileitis with multiple small bowel perforations in a young man with human immunodeficiency virus (HIV) infection. The patient developed abdominal pain with diarrhea and fever, and eventually acute abdomen with pneumoperitoneum. The patient had poor prognosis and deceased despite the prompt surgical intervention and the antiviral therapy he received. At pathology a remarkable finding was the presence of viral inclusions in smooth muscle fibers. The destruction of muscle cells was the main cause of perforation.

CONCLUSION

Morbidity and mortality associated with perforation from CMV enteritis in AIDS patients are high and the life expectancy is short. Cytomegalovirus disease is multifocal; therefore, excision of one portion of the gastrointestinal tract may be followed by a complication elsewhere. Our case elucidate that muscle cell destruction by the virus is a significant cause leading to perforation.

Upper gastrointestinal bleeding in a young female with AIDS: a case report

Upper gastrointestinal haemorrhage (UGIH) is a surprisingly common condition in patients with AIDS (PWAs), affecting at least 6%. With the growing number of PWAs and their increasing life span, UGIH will certainly gain importance as a diagnostic and therapeutic challenge to health-care professionals, especially in central and eastern Europe because of the AIDS epidemics rapidly developing in that region. With the scarcity of reported cases, lack of management guidelines of UGIH in PWAs, and limited therapeutic possibilities in developing countries, important therapeutic problems should be anticipated. We present a case of UGIH in a female PWA due to ketoprofen overuse, successfully managed with conservative treatment.

Human immunodeficiency disease: how should it affect surgical decision making?

BACKGROUND

The ever-increasing prevalence of human immunodeficiency virus (HIV) infection and the continued improvement in clinical management has increased the likelihood of surgery being performed on patients with this infection. The aim of the review was to assess current literature on the influence of HIV status on surgical decision-making.

METHODS

A literature review was performed using MEDLINE articles addressing "human immunodeficiency virus," "HIV," "acquired immunodeficiency syndrome," "AIDS," "HIV and surgery." We also manually searched relevant surgical journals and completed the bibliographic compilation by collecting cross references from published papers.

RESULTS

Results of surgery between noninfected and HIV-infected individuals and between HIV-infected and acquired immunodeficiency syndrome (AIDS) patients are variable in terms of morbidity, mortality, and hospital stay. The risk of major surgery is not unlike that for other immunocompromised or malnourished patients. The multiple co-morbidities associated with HIV infection and the availability of highly active antiretroviral therapy must be considered when assessing and optimizing the patient for surgery. The clinical stage of the patient's disease should be evaluated with a focus on the overall organ system function. For patients with advanced HIV disease, palliative surgery offers relief of acute problems with improvement in the quality of life. When indicated, diagnostic surgery assists with further decision-making in the medical management of these patients and hence should not be withheld.

CONCLUSION

HIV infection should not be considered a significant independent factor for major surgical procedures. Appropriate surgery should be offered as in normal surgical patients without fear of an unfavorable outcome.

Recurrent histoplasmosis in AIDS mimicking a colonic carcinoma

The prevalence rate of lower gastrointestinal bleeding in patients with AIDS is around 2.6%. A 42-year-old woman with AIDS (CD(4) count 9/microL) and recently treated for disseminated histoplasmosis presented to the emergency room with melena, severe anaemia and fever. A colonoscopy showed an umbilicated colonic nodule mimicking a carcinoma of the colon. The biopsy showed intracytoplasmic microorganisms compatible with Histoplasma capsulatum. She had poor compliance to the itraconazole when discharge on previous admission. Despite the fact that colonic histoplasmosis is uncommon, the mortality rate is around 8% and clinicians should be aware of the clinical presentation of histoplasmosis when recur, especially in patients not taking the itraconazole for long-term treatment.

Cytomegaloviral colitis in HIV positive patients: endoscopic findings

BACKGROUND

Diarrhea in seropositive human immunodeficiency virus patients is one of the most important and disabling symptoms, and often decreases their quality of life. Cytomegalovirus colitis is among the principal causes of this symptom and colonoscopy is the gold standard examination to diagnose it.

AIM

To define the main endoscopic findings in seropositive human immunodeficiency virus patients with cytomegalovirus colitis.

METHODS

Two hundred and forty-three colonoscopies were performed in 200 seropositive human immunodeficiency virus patients with diarrhea associated or not to abdominal pain or gastrointestinal bleeding, over 10-year period, whom 51 patients were diagnosed with cytomegalovirus colitis. Full length colonoscopy with ileum intubation was always tried and multiple biopsies of all segments examined, including endoscopically normal segments, were attempted. All diagnoses were confirmed by histologic and immunohistochemical studies.

RESULTS

Total colonoscopy was possible in 98.03% and ileum intubation in 88.23% of these cytomegalovirus colitis patients. At colonoscopy, a heterogeneous ulcerative pattern was presented in 72.54%, an inflammatory process of the mucosa in 21.56% and 5.88% of the patients mucosa was endoscopically normal.

CONCLUSION

Full length colonoscopy with ileum intubation and multiples biopsies of all segments, even when they are endoscopically normal, have always to be attempted in cases of seropositive human immunodeficiency virus patient with diarrhea.

Management of lower gastrointestinal tract bleeding

Acute bleeding from the colon and rectum is less frequent and less dramatic than haemorrhage from the upper gastrointestinal tract. In most cases, bleeding from the colon and rectum is self-limiting and requires no specific therapy. Diverticula and angiectasias are the most frequent sources of bleeding. Malignancy, colitis (inflammatory bowel disease, non-steroidal anti-inflammatory drugs, and infectious colitis), ischaemia, anorectal disorders, postpolypectomy bleeding, and HIV-related problems are less frequent causes. The recurrence rate, especially in diverticular bleeding, is high. Resuscitation and haemodynamic stabilisation of the patient is the first step in the management of colonic bleeding. Urgent colonoscopy is the method of choice for diagnosis and therapy. By analogy with peptic ulcer bleeding, risk stratification using stigmata of haemorrhage is gaining more importance. Modern endoscopic techniques such as injection therapy, thermocoagulation and mechanical devices seem to be effective in achieving haemostasis and avoiding precarious surgery. Angiography and nuclear scintigraphy are reserved for those patients in whom colonoscopy is not possible or has repeatedly failed to localise the bleeding site.

Trends in perimortal conditions and mortality rates among HIV-infected patients

OBJECTIVES

To describe trends in perimortal conditions (pathological conditions causing death or present at death but not necessarily the reported cause of death) during three periods related to the availability of HAART, pre-HAART (1992-1995), early HAART (1996-1999), and contemporary HAART (2000-2003); annual mortality rates; and antiretroviral therapy (ART) prevalence during 1992-2003.

DESIGN

Multicenter observational clinical cohort in the United States (Adult/Adolescent Spectrum of HIV Disease [ASD] project).

METHODS

Proportionate mortality for selected perimortal conditions, annual mortality rates, and ART prevalence were standardized by sex, race/ethnicity, age at death, HIV transmission category, and lowest CD4 cell count of ASD decedents. Multivariable generalized linear regression was used to estimate trends in proportionate mortality, as linear trends through all three HAART periods, mortality rates, and ART prevalence.

RESULTS

Of 9225 deaths, 58.6% occurred during 1992-1995, 29.5% during 1996-1999, and 11.9% during 2000-2003. Linear trends in proportionate mortality for noninfectious diseases (e.g., liver disease, hypertension, and alcohol abuse) increased significantly; proportionate mortality for AIDS-defining infectious diseases (e.g., pneumocystosis, nontuberculous mycobacterial disease, and cytomegalovirus disease) decreased significantly. Mortality rates decreased from 487.5/1000 person-years in 1995 to 100.6 in 2002. Of 36 256 patients from ASD, 75.7% (standardized average) were prescribed ART annually.

CONCLUSIONS

Among HIV-infected patients, the majority of whom were prescribed ART, the increasing trend in common noninfectious perimortal conditions support screening and treatment for these conditions in order to sustain the trend in declining mortality rates.

Cytomegalovirus cholangitis presenting with recurrent hemobilia

Cytomegalovirus (CMV) cholangitis is a rare manifestation of CMV infection that has previously been described only in HIV-infected patients and solid-organ-transplant recipients. Reported here is a case of CMV cholangitis that occurred in a patient on chronic corticosteroid therapy who presented with recurrent hemobilia and biliary obstruction and was successfully treated with ganciclovir and cholecystostomy. A search of the medical literature revealed no previous case of this kind.

Gastrointestinal hemorrhage: is the surgeon obsolete?

The management of GI hemorrhage has undergone tremendous evolution in recent decades. Once commonly managed by surgeons, the almost continuous introduction of new technologies and pharmacotherapies has dramatically improved clinicians' ability to identify and control sources of bleeding without surgery. Although a gastroenterologist can successfully manage most cases of GI hemorrhage endoscopically, surgical consultation remains an important consideration for the emergency physician in selected cases.

Infectious diarrhea in human immunodeficiency virus

Chronic HIV-associated diarrhea is currently a field in flux. Improved noninvasive diagnostic tests, improved pathogen-specific regimens, and better empiric therapies may change some of the assumptions used to select algorithms for diagnostic evaluation and management. Any shift in the cause of diarrhea from pathogen-associated to idiopathic or a reduction in the overall incidence of diarrhea would have considerable impact. It is unclear how significant the problem of pathogen relapse in previous responders will become. Existing studies reviewed in this article show that the high diagnostic yield of endoscopy when stool tests are negative, coupled with significantly better outcomes when pathogens are identified, support the current practice of routine endoscopic evaluation. There currently are scant data on the economic impact of HIV-associated diarrhea as it relates to pathogen-specific and empiric therapy in the era of protease inhibitors. Such data would be integral to future evaluation of the impact of diagnostic and therapeutic strategies.

Viral causes of diarrhea

Viruses are important causes of diarrhea. In healthy adults, the main clinical manifestation is acute, self-limited gastroenteritis. Advances in molecular diagnostics have shown that epidemics of acute gastroenteritis most frequently are due to caliciviruses spread through contaminated food or through person-to-person contact. Application of similar technology is needed to make a definitive statement about the role of such candidate viruses as rotavirus, astrovirus, and adenovirus as the cause of nonepidemic acute gastroenteritis in adults. Rarely a previously healthy adult gets acute CMV colitis. CMV and EBV mainly cause diarrhea in immunocompromised patients, however. Advances in prophylaxis and treatment have reduced the frequency and severity of these diseases. Acute infantile gastroenteritis is caused by rotavirus, calcivirus, astrovirus, and adenovirus. These viral diseases of the gut are seen by the physician as routine and rare clinical problems.

Lower intestinal bleeding

Lower gastrointestinal tract bleeding is a frequent cause of physician consultations and hospital admissions. Clinical presentation is predictable and significantly influences subsequent patient management. Controversy surrounding diagnosis and treatment of lower gastrointestinal bleeding results from a surprising lack of prospective controlled data. Thus, selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithm approach. Advances in endoscopic, radiological and surgical equipment and techniques offer promising new diagnostic and therapeutic modalities, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. The present chapter will address clinical presentation, aetiology, diagnosis and treatment of lower gastrointestinal tract bleeding.

Gastrointestinal manifestations of HIV infection

Since the beginning of the AIDS pandemic, gastrointestinal (GI) problems have been among the most common features of the disease. Despite the introduction of highly active antiretroviral therapy (HAART) in 1995 and 1996, most HIV-infected patients continue to have GI complications. The clinician must be able to diagnose and treat the opportunistic gastrointestinal infections and neoplasms that occur in the advanced AIDS patient, as well as the treatment-induced symptoms and non-HIV-related GI disorders that predominate in early HIV disease. This review addresses the GI manifestations of HIV, with particular emphasis on new developments in the era of highly effective therapy.

Outcome of AIDS-associated cytomegalovirus colitis in the era of potent antiretroviral therapy

The effect of protease inhibitors (PIs) on the outcome of AIDS-associated cytomegalovirus (CMV) colitis is unknown. The aim of this study was to determine the impact of PIs on the recurrence of CMV disease and long-term survival in a large cohort of acquired immunodeficiency syndrome (AIDS) patients with CMV colitis. We reviewed the medical records of 252 AIDS patients who were diagnosed with CMV colitis by colonoscopy between January 1992 and January 1997 at Bellevue Hospital (New York, NY, U.S.A.). Follow-up data were obtained from chart review and direct telephone contact. A complete response to ganciclovir and/or foscarnet therapy was seen in 87.0% of the patients. Recurrence of CMV colitis occurred in 53.1% of patients and was significantly less common in those who received maintenance therapy (36.1% vs. 56.7%; p = 0.03) and in those who were treated with PIs (22.8% vs. 71.9%; p < 0.001). During follow-up. 69.3% of patients died. Multivariate analysis using Cox regression showed that mortality was increased in patients with recurrent CMV colitis (relative risk [RR] of death, 1.7: 95% CI, 1.1-2.6; p = 0.02) and comorbid disease (RR, 1.5: 95% CI, 1.1-2.2; p = 0.02), and decreased in those who were treated with PIs (RR, 0.42; 95% CI, 0.3-0.7; p = 0.001). The median survival was 71 weeks and was significantly longer in patients who were treated with PIs than in those who did not receive these potent anti-retroviral medications (99 vs. 51 weeks; p < 0.001). PIs significantly improve the outcome of AIDS-associated CMV colitis.

Viral infections of the gastrointestinal tract

Acute gastroenteritis is common in adults. It can occur in institutional epidemics or epidemics of food-borne illness; in these cases, caliciviruses are the major cause of the condition. When acute gastroenteritis occurs in nonepidemic form, its causes are less clear. It may be due to caliciviruses or to the less common serotypes of childhood gastroenteritis viruses, such as rotavirus, astrovirus, and adenovirus. The pathogenesis of acute viral gastroenteritis is not completely understood. Old evidence suggests that mild villus damage is responsible, but new evidence indicates that active secretion and motility disturbance may be involved in the production of symptoms. Five common viruses can remain latent in gastrointestinal tissues and produce disease many years after initial infection. Two major herpesviruses, cytomegalovirus and herpes simplex virus, cause ulcerative disease of the gastrointestinal tract. This disease occurs in healthy persons but is more common and more severe in immunocompromised patients. Three other viruses--Epstein-Barr virus, human papilloma virus, and human herpesvirus-8--are implicated in benign and malignant proliferative diseases of the gastrointestinal tract. Epstein-Barr virus has been associated with immunoproliferative disease after transplantation and may also cause small-bowel and colonic lymphoma in healthy adults. It causes most AIDS-related lymphomas. Human papillomaviruses cause anorectal condyloma and anal cancer. Human herpesvirus-8 causes gastrointestinal Kaposi sarcoma.

Risk factors for recurrent bleeding and mortality in human immunodeficiency virus infected patients with acute lower GI hemorrhage

BACKGROUND

Little is known about lower gastrointestinal (GI) hemorrhage in the human immunodeficiency virus (HIV) infected population. Our aim was to determine the underlying causes, the clinical outcome, and the risk factors for recurrent bleeding and mortality in HIV-infected patients with acute LGIH.

METHODS

We reviewed the medical records of consecutive HIV-infected patients with acute lower GI hemorrhage who were evaluated with endoscopy from January 1992 through January 1997 at Bellevue Hospital Center.

RESULTS

During the 5-year study period, 312 patients with acute lower GI hemorrhage underwent colonoscopy (n = 233) or flexible sigmoidoscopy (n = 79). Cytomegalovirus colitis (25.3%), lymphoma (12.2%), and idiopathic colitis (12.2%) were the most common causes identified. Within 30 days of presentation, recurrent bleeding occurred in 17.6% of patients. Independent predictors of recurrent bleeding included the presence of at least one comorbid illness, a hemoglobin level of less than 8 gm/dL, a platelet count of less than 100,000/mm3, and major stigmata of hemorrhage. The 30-day mortality from lower GI hemorrhage was 14.4%, and the presence of comorbid disease, recurrence of bleeding, and surgical intervention were found to be the only independent predictors of mortality in this patient population.

CONCLUSIONS

Acute lower GI hemorrhage in HIV-infected patients is most commonly caused by cytomegalovirus colitis and is associated with a high short-term morbidity and mortality.

Gastrointestinal hemorrhage in patients with AIDS

Gastrointestinal (GI) bleeding is a relatively infrequent complication seen in patients with AIDS. As with non-HIV-infected individuals, upper GI bleeding is much more common than lower GI bleeding. In patients with AIDS, upper GI bleeding can result from etiologies related to underlying HIV infection [cytomegalovirus (CMV), Kaposi's sarcoma, idiopathic esophageal ulcers, etc] or be unrelated to HIV infection (peptic ulcer, portal hypertension, Mallory-Weiss tear, etc.). Lower GI bleeding is caused predominantly by etiologies related to underlying HIV disease; CMV colitis is the most common cause. In contrast to non-HIV-infected individuals, hemorrhoids and anal fissures can result in significant bleeding in AIDS patients because of associated thrombocytopenia. Management of GI bleeding in AIDS patients is similar to patients without HIV infection, and includes resuscitation, identification of the bleeding source, achieving hemostasis, and preventing recurrent bleeding. Several etiologies that cause GI bleeding in patients with AIDS can be diagnosed through endoscopy, either by their characteristic endoscopic appearance or mucosal biopsies.

Gastrointestinal infections in the immunocompromised host

Gastrointestinal infections are a frequent and important complication of immunodeficiency diseases and immunosuppressive therapy. Such infections may be severe, prolonged, or even fatal, whereas the same infections are typically mild and transient in immunocompetent persons. In this regard, the strong association between HIV-induced immunosuppression and the increased prevalence of severe enteric infections is strong evidence of the link between immune function and defense against enteric pathogens. Because gastrointestinal infections in immunocompromised persons are frequently severe and life-threatening, a vigorous approach to the diagnostic evaluation and therapeutic management is advocated by many clinical investigators. In this review, we summarize the important new developments, particularly during the past year, regarding gastrointestinal infections in immunocompromised persons.

Diagnosis and treatment of colonic disease in AIDS

The colon is a frequent site of gastrointestinal complications in patients with HIV infection, and these colonic disorders increase in frequency as immunodeficiency worsens. The most common clinical manifestations of colonic disease in AIDS are diarrhea, lower gastrointestinal bleeding, and abdominal pain. Toxic megacolon, intussuseption, typhlitis, idiopathic colonic ulcer, and pneumatosis intestinalis also have been described. In the HIV-infected patient with preserved immunity, the most common cause of colitis is bacterial, but as the degree of immunodeficiency worsens, opportunistic pathogens (CMV, protozoa, mycobacteria, fungi) and neoplasms become more frequent. The frequent use of antibiotics, chemotherapeutic agents, and frequent hospitalization increase the susceptibility to cf2Clostridium difficule cf1colitis. Endoscopy plays an integral role in the management of many colonic disorders in AIDS.